Assertive outreach is a low-cost and effective way of helping severely mentally ill people. And its proponents believe it could be the saviour of community care.
As ministers complete work on their review of mental health policy, the system, whereby specialist teams keep track of this 'difficult to treat' client group around the clock, is increasingly being promoted as the way forward.
Earlier this month the Sainsbury Centre for Mental Health published a major report trumpeting assertive outreach as the approach that can effectively tackle failures in care. It is also considerably cheaper than treating patients in secure hospitals.
Ministers and Department of Health officials are said to be examining the approach, along with crisis intervention and nurse care services.
Although assertive outreach has only recently come to prominence, one London charity has been using it for eight years with great success.
Tulip, based in offices in Wood Green, north London, was set up 10 years ago this week.
Its original aim was to provide residential places in the community for patients released from long-stay hospitals.
But it was not long before it began to look at addressing the needs of people enmeshed in a cycle of mental distress characterised by breakdown, admission to hospital and homelessness.
Now the charity, jointly commissioned by Enfield and Haringey health authority and Haringey council to provide all outreach services in the borough on a£1m-a-year contract, supports around 150 clients under the system.
Most clients are young, unemployed, living in appalling housing conditions and extremely isolated, says Andrew Law, a team leader of the outreach service at Tulip.
Most also have a diagnosis of schizophrenia or have another psychotic disorder. They tend to have chaotic lifestyles and are likely to to be alcohol or drug abusers. They may also be violent and are at high risk of suicide or self-harm.
For a number of reasons, including fear and mistrust, the service has had difficulty engaging with these so-called revolving-door patients, who often fail to turn up for appointments and avoid taking their medication.
But the persistence and flexibility of Tulip's two outreach teams - one funded through the Sainsbury Centre initiative - has paid off. 'We will not allow people to slip through the net if it can be helped, ' says Mr Law.
'We go out and visit the clients wherever they are, be it in their own homes, bed and breakfast, in hospital, prison or on the streets.
'We see them at the same time on the same day every week. If they miss an appointment we look at whether a different time may be suitable, and we will take them breakfast at 8am if necessary.'
The teams are in close contact with the statutory services and alert them if they are having problems engaging with a client. In most cases they have been able to overcome difficulties.
An evaluation of the work of one of the Tulip teams shows it keeps in constant touch with clients in 94 per cent of cases, and over the three-year evaluation period only one client was lost to the service. Tulip compares this with the third or so of clients that it claims become lost to health and social services.
Outreach clients are being admitted to hospital less frequently. In the first year of operation of the service the number of hospital bed days required by clients fell by 322, a decrease that has been maintained.
It is not persistence alone which has achieved this success. The Tulip teams target specific groups, and the racial and cultural make-up of the teams reflects as far as possible that of the clients they serve.
One team draws 85 per cent of its clients from black and ethnic minority communities. The five-strong team is made up of three Afro-Caribbean women, one Afro-Caribbean man and one white man.
The second team is targeted at the Asian and Cypriot communities, at refugees and at women. It consists of one white man, one white woman, one Asian man, one Afro-Caribbean man and one Afro-Caribbean woman.
Some team members are social workers, nurses or psychotherapists.
Others, from a variety of backgrounds, are highly experienced in working with severely mentally ill clients.
All assertive outreach workers receive ongoing training as well as management and clinical supervision.
Tulip does not use key workers, but has fostered an approach in which an appropriately skilled team member will be assigned to look after the needs of particular clients.
Trinidad Navarro, the charity's director of clinical practice, says the team as a whole assumes responsibility for each client, and all team members know and work with each client.
Clients are gradually introduced to each team member and they are encouraged to be dependent on the service as a whole rather than on an individual caseworker.
This allows for more continuity, as clients do not need to be reassigned if a worker is on leave or quits. And cases are never closed, so clients can start engaging with the service again at any time they like.
'The previous history of clients is that they have felt let down by individuals and services, ' says Deborah Davidson, Tulip's executive director. 'But the team approach helps to overcome this.'
She says team members will do anything to help clients avoid unnecessary hospital stays, whether it means clearing up their flats, helping them fill out forms or get funding for college courses, or sleeping at their home in times of crisis.
Even when clients are admitted to hospital, the team will ensure that their home is kept running, and can arrange, among other things, for pets to be fed and benefits to be paid if necessary.
Ms Davidson highly recommends the assertive outreach approach but warns that the staff must be recruited carefully.
'Not everyone can do it, ' she says.
'You need people who are engaged in the community, who connect in some way with the cultural and family background of clients.'
She worries that the government's mental health review will push all services into the statutory sector because of public fears about mentally ill patients.
'This will lead to people being excluded, ' she says.
She argues that the voluntary sector has an important role to play in providing services. Its strength, she says, lies in 'advocating on behalf of the community'.
'It is going out there and assertively advocating on behalf of clients that enables us to target services to those whom others cannot reach, ' she says.
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